Novel Technique for Epinephrine Removal in New Generation Autoinjectors

Anaphylaxis is a severe, life-threatening, multisystem hypersensitivity reaction that can rapidly progress to hypotension and airway compromise. This process is one of the most variable, rapidly progressing, and critical illnesses that one may encounter in the wilderness or austere environments. It can affect persons without a known history of allergic reactions or anaphylaxis. Anaphylaxis is often only responsive to epinephrine. Successful management of anaphylaxis has been documented with the use of prescription epinephrine pens that require minimal training for safe use. Depending on body habitus, these pens may deliver intramuscular or subcutaneous epinephrine. These commercially available autoinjectors are produced for single use, but have been found to contain multiple additional doses within the device. Although the autoinjectors were intended for a single use for stabilization, in an austere setting where access to hospitals or emergency medical services is often limited, a patient with anaphylaxis may require additional doses of epinephrine before reaching definitive care. People often do not carry extra autoinjectors. Previous publications have demonstrated successful techniques to safely remove the additional epinephrine from the frequently used EpiPen. However, automated electronic autoinjectors are now becoming more widely available, and it is the intention of this report to demonstrate a safe and effective way to remove additional doses from this new product.

The Auvi-Q is a battery-powered, automated epinephrine-delivery device manufactured by Sanofi-Aventis US. When the device is removed from its plastic case, it turns on and automatically provides audio instructions to the user to direct its use. When pressed against the patient’s anterolateral thigh, a compressed CO₂ mechanism extends the needle for 5 seconds. This is the time required to deliver the full dose of epinephrine, after which the device automatically retracts the needle safely into the device. Although these devices are sold in a two-pack, patients frequently only have one in their possession. The Auvi-Q, along with previously produced autoinjectors, contains additional doses of epinephrine and, if disassembled properly, contains materials necessary to deliver the remaining epinephrine. This represents off-label use and is not recommended or sanctioned by the manufacturers of these devices. It should only be attempted in situations in which there are no other options for epinephrine delivery.

This article describes one stepwise approach to accessing the additional doses of epinephrine from the Auvi-Q device. It is imperative that any provider attempting to gain access to the additional epinephrine within the device recognize that there is now a used needle within the autoinjector. This needle will be reused, so the device cannot be used for multiple patients. Efforts should be made to observe safe handling techniques as well as to wear protective gloves and eyewear.

Step 1: After correctly deploying the initial dose of epinephrine according to the automated directions provided by the Auvi-Q, begin removing the sticker surrounding the device. Hold the side with the speaker and back hatch facing up (Figure 1).

Step 2 (optional): Using a flathead screwdriver (or similar tool), open the battery hatch. This will allow you to remove the batteries, and the device will stop talking (Figure 2).

Step 3: Using a screwdriver, gently wedge, tap, and pry the bottom edge of the device apart from the main body (bottom edge is the side opposite of the needle). Save the bottom of the casing, as you will need this later. The spent CO₂ cartridge can then be removed (Figure 3).

Step 4: In the middle of the casing there is a rubber sealant, which must be removed from the device to release the syringe (Figure 4).

Step 5: When the sealant is removed, a green plastic piece surrounding the glass vial can be seen (Figure 5). Chip away the extra white plastic until it easily slides out.

Step 6: Carefully slide the green apparatus from the outer casing. Be careful as there is a used needle attached.

Step 7: After sliding the syringe and green encasement out of the device, gently bend the green plastic away from the vial as it serves as the stopper to prevent additional dosing of epinephrine while in the autoinjector (Figure 6).

Step 8: The vial and casing can then be used as a free syringe. Each dose is approximately the size of one plunger movement. After one additional dose, the white plunger will hit the top of the vial (Figure 7).

Step 9: Improvisation can lead to several options for getting the third and final dose. One of the simplest methods we have discovered is to remove the clear plastic driver for the plunger and then use the bottom piece of the casing you removed earlier to inject the remaining epinephrine (Figure 8).

These steps are illustrated in the online supplementary video.

With minimal tools (ie, a flat-head screwdriver and pliers), this approach allows additional epinephrine to be accessed from the Auvi-Q device. After dismantling the device, there appear to be 2 additional doses. Although we dismantled an Auvi-Q junior, we believe this information is generalizable to the 0.3-mg, adult model.

Because of reports of inaccurate dose delivery in current models, Sanofi US has voluntarily recalled these devices and is not distributing the Auvi-Q at this time. As this is a voluntary recall, these devices may remain in public hands. Sanofi US has not released any information regarding reintroducing the product to the market. It is not known whether future models will have similar designs to the Auvi-Q that will allow application of this epinephrine removal technique.

Anaphylaxis is a severe, life-threatening illness that requires administration of epinephrine. Although this article does describe a novel technique for removing epinephrine from the Auvi-Q autoinjector, patients experiencing anaphylaxis need definitive care as soon as possible, and this should not be treated as an alternative option to seeking care. This technique is intended to be used only in resource-limited and austere environments. We hope this spurs additional research and discussion regarding other techniques for epinephrine retrieval in these newer generation autoinjectors.

Thanks to Lisa Uherick, MD, for donation of the expired Auvi-Q junior, which spurred interest in this project.